Health Budget: Limpopo, North-West, Northern Cape Input

Meeting report

HEALTH PORTFOLIO COMMITTEE
16 April 2003
HEALTH BUDGET: LIMPOPO, NORTH-WEST, NORTHERN CAPE INPUT

Chairperson: Mr. L. Ngculu (ANC)

Documents handed out
Limpopo Province Presentation
North-West Province Presentation
Northern Cape Presentation
Department of Health budget: Vote 16 (link to Treasury website)

SUMMARY
The Committee heard from the Limpopo Department of Health that the increased incidence of criminal activity had seriously impacted on the roll-out of a 24 hour service in rural clinics.
Achievements included the staff establishment component being reviewed and a review of the structures for the district offices, district hospitals, regional hospitals and level thirteen district hospitals, specialized hospitals including four revitalization project hospitals had been finalized. The fleet audit had been completed and a vehicle replacement plan had been developed.

North West Province Department of Health had witnessed a relative decline in the number of people visiting district hospitals in preference for the Primary Health Care facilities that had been set up. The Department was working hard to expand and improve the quality of service offered at the Primary Health Care establishments noting that the Department had devised a mechanism for a daily doctor visit to these facilities. However, there was a huge gap between the programmes the Department wished to roll out especially in rural out posts. A sum of R 120 million had been received to capacitate the personnel component and there were plans to develop a range of incentives to attract health professionals and at the same time improve emergency and financial services in district hospitals.

Northern Cape Department of Health stated that emphasis would be put on accelerated service delivery. One of the major areas of concern to be addressed rates through integrated strategic interventions was the decreasing morbidity and mortality. Other key areas included: revitalization of hospital services, improving human resource development and management, reorganization of support services, legal reform programme and improving resource mobilization and management of resources without neglecting the attainment of equity in resource allocation.

MINUTES
Briefing by Dr. Manzini - HOD Limpopo
Dr. Manzini outlined the Department's vision which she said was to be a caring and developmental health and welfare system which promoted well-being, self-reliance and humane society in which all people in the Northern Province had access to affordable and good quality services. The Department's mission would be achieved through the provision of a ccomprehensive, integrated and equitable Health and Welfare services which was sustainable, cost effective and focussed on the development of human potential in artnership with relevant stakeholders.

Dr. Manzini noted that the Department's core functions were namely: to provide regional and specialised hospital services including academic Health Services, to render and co-ordinate Medical Emergency Services,  render Medico-legal services and the quality control of all health services and facilities. The other functions were to formulate and implement provincial health policies, norms, standards and legislation, to develop & manage District Health Services and to provide technical and logistical support to health districts. The Department would also render specific provincial services programmes such as a TB programme and make provision for non-personal health services. The Department would also make provision for and maintain Health Care Technologies and research on, monitor and evaluate health services/programmes.

Dr. Manzini outlined the achievements the Department had made so far noting that the staff establishment component had been reviewed and that a review of the structures for the district offices, district hospitals, regional hospitals and level thirteen district hospitals, specialized hospitals including four revitalization project hospitals had been finalized. She added that 1110 vacant posts had been filled and that this number also included doctors and nurses noting however that the Department was faced with an employees turnover rate of 6,03% and that this incidence left a vacancy rate of 41,2%.

The Department had finalized its fleet audit and that a vehicle replacement plan had been developed. It had been established that a total of 93 new vehicles had been ordered and this included 40 Ambulances, 8 response vehicles, 25 pool cars for hospital administration and 20 for mobile services. The major constraint was that these vehicles took a long time to be delivered and that out of the entire fleet, a sum of 355 vehicles have travelled more than 200 000-400 000kms. The Department had to date complied with the Department of Labour's requirement with regard to submission of Equity progress reports noting that the Department had achieved 70/30 targets.

Dr. Manzini reported that twenty Community Based Organizations were currently offering ICHBC services and that 25,666 clients were being attended to. Six hundred and thirty six Caregivers had been trained and offered ICHBC services to 3641 orphans of which 2157 were HIV/AIDS orphans. However, Community Home base care kits were not always available to all clients. TB case detection rate had increased from 6468 in 2000 to 7793 in 2001 and that overall TB cure rate had improved from 52,8 in 2000 to 53,2% 2001. Approximately 80% PHC facilities provide IMCI which result in a reduction of incidences of diarrhea from 16.2 in 2001 to 13.5 in 2002, and upper respiratory infections from 25.1 in 2001 to 23.4 in 2002.

Regarding the roll-out of Nutrition programme Dr. Manzini reported that 68 of the 105 projects were sustainable and that at present a total of 2747 schools were participating. The programme was slowed by logistical and management problem. The 24-hour services had increased from 183 to 233 clinics. Ten clinics had an increased hour of services from eight hours to twelve hours. Security at the clinics could not be improved everywhere and clinics with inadequate security would not be able to provide 24 hour services. Lack of security would also have a detrimental effect on retention and recruitment of staff and that this situation would negatively impact service delivery at the clinics.

Discussion
Ms Malumise (ANC) referred to the Department's list of areas of priorities and noted that Aids was a major concern yet it is not listed as one of the major causes of death. Why was Aids not listed as a major contributor to deaths in the province.

Dr. Manzini explained that Aids was not per se a cause of death noting that a patient eventually died due to TB, upper respiratory complications or renal failure among other Aids related illnesses but not Aids.

Ms Malumise asked if the province experienced the theft of food, linen and other medical stores as in other provinces.

Mr. Moloto admitted that there were indeed cases of theft and pointed out that the Department was taking security issues seriously noting that personal searchers had been introduced in order to curb incidents of staff pilferage.

Dr. Jassat (ANC) noted that there was an item that suggested that 53% of death resulted from "undetermined causes" and wondered whether the HIV/Aids pandemic fell under this.

Dr. Jassat asked the cause of the increased lower respiratory complications.

Dr. Manzini noted that the lower respiratory complication was one serious challenge but stated that the Department did not have anything called 'burden of disease' which she observed was a necessary barometer on the incidence of a given ailment. The Department was currently studying the provincial norms and standards in order to form a basis for intervention and hoped that by end of the year the Department would have developed a document on the burden of disease.

Dr. Jassat asked how the Department gauged patient satisfaction with services that are rendered at its various institutions.

Mr. Moloto - MEC for Health - explained that the Department did its best to provide quality services and that suggestion boxes were posted at strategic places at all healthcare institutions in addition to periodical questioners that were sent to patients for feedback. He regretted, however, that due to the high levels of illiteracy in the province not much meaningful response came from the patients.

Ms Baloyi (ANC) expressed concern at the increased maternal morbidity and enquired about the percentage of clinics that offer delivery services.

Dr. Manzini replied that she did not have the relevant data on the percentage of clinics at the moment but noted that data collection was still a huge problem and that the Department was unable to properly interpret the available figures in order to ensure appropriate intervention. The Department was presently looking into the problem but that quite a huge ground was yet to be covered before the problem was unravelled.

Ms Baloyi said that it was unfortunate that mobile clinic services had collapsed yet the rural nature of the province dictated that urgency for such a service. What was the Department doing to address this problem?

Dr.Manzini explained that Mobile Clinic Services collapsed due mainly to the escalating problem of insecurity wherefore some nurses were even raped. She also attributed the failure to constant vehicular breakdown noting that the Department's fleet had covered many kilometers and that this let to the collapse of the facility mid last year. Provision of mobile services was one of the priorities listed in the strategic plan and that her Department was looking into ways to revive this critical service.

Mr. Moloto noted that in the past the province did not lay much emphasis on crime prevention since this was not a major source of worry but that due to the intense activity generated by security operations in Gauteng criminals had fled to the province where they were wrecking havoc. This development forced the Department to rethink its position on security measures since the menace had contributed to the collapse of the mobile clinics while at the same time adversely affecting the provision of the 24hrs service at various clinics.

Ms Baloyi noted that the Department had not clearly detailed how it intended to achieve its stated priorities within the current budgetary allocations.

Dr. Manzini replied that her Department had developed a comprehensive Strategic Plan - copies of which would be supplied to members in due course, which laid out in considerable detail how the Department would go about implementing the stated priorities.

Ms Baloyi singled out the equity gap, which she said was a source of great worry. How would the Department address this?

Mr. Moloto admitted that the issue of inequity was a huge challenge noting that within the province its incidence was patterned along the black and white divide. The existing infrastructural imbalance fuelled the sad scenario of inter-provincial inequities noting that for instance the Gauteng province boasted national roads and therefore, unlike Limpopo it did not need to make budgetary provision for the road infrastructure. Gauteng also had about five national hospitals that were budgeted for nationally which helped to deepen the problem of inter-provincial inequities. He pointed out that as much as the province - within its limited capacity - tried to address inequity, more work was called for at the national policy making level in order to make an effective dent on the issue of inter-provincial inequity.

The Chair offered that part of the problem with regard to inter-provincial inequity was not budgetary fundamentals per se but that lack of political preparedness among the provinces to address the competing challenges. He singled out the objectionable equation in the province where 39% of the budget was allocated to education whilst a mere 16% went to health. This manner of budgetary allotment was unfortunate noting that if there was no political preparedness amongst the provincial leadership then the issue of budgetary inequity would continue to plague the nation.

Ms Mabeta (ANC) asked who was responsible for the provision of kits that were used in the roll-out of the home based care HBC given that for the most part lack of these tools hampered progress.

Dr. Manzini replied that initially the Department had an ordering system for the HBC kits but that it could not cope with the demand and so it had resorted to adapt the route of configuring for a better audit.

Dr. Cachalia (ANC) asked the Department to comment on the question of the high rate of staff turn-over in the province.

Dr. Cachalia observed that it would be prudent for the Department to internalize the culture of routine maintenance for its vehicle fleets in order to avoid a situation where service delivery exercise came to a halt due to lack of transport. Was the maintenance item provided for in the budget?

Dr. Manzini replied that the Department had decided to decentralize the transport system and that vehicle are regularly maintained as a standard practice.

Ms Malumise asked the percentage of population that was affected by the Aids pandemic and how many PMCT sites had so far been set up.

Dr. Manzini replied that the official results showed a prevalence rate of 14.2% and that the Department was still waiting for the updated figures. The PMCT roll-out had been implemented in eight hospitals and two district hospitals while Naviropine was offered in all the hospitals. The Department planned to roll out the programme in all the district hospitals especially now that the budgetary allocation for HIV/Aids had increased significantly.

The Chair queried the Department's position that Aids was not a cause of death noting that in this time and age it was feasible to determine whether the cause of death was Aids related and wondered whether the Department's intervention mechanisms responded to such an analysis.

Dr. Manzini explained that clinically when a patient presented with an illness, it was possible to determine whether or not it was Aids related but that such determination did not record the Aids as a notifiable disease as such. Until agreement was reached at the National level to rate Aids as a notifiable disease for the present all legal documents would show that one died of an Aids related illness and not Aids.

The Chair noted that there was an increased budgetary allocation to the Department both on the equity share and the conditional grant facility and asked if the Department had prepared a business case to apply this expanded budgetary kitty.

The Chair noted that about R500 million had been set aside for rural services incentives and asked what plans the Department had put in place to apply these funds to curb help professions leaving the Department.

Dr. Manzini said the Department was developing a business plan for the rural incentives but regretted that the package covered doctors only and that the Department was looking into ways to incorporate other allied workers.

Mr. Moloto noted that the Department had received communication that a sum of R12 million would be dispersed for rural incentives in the province. This figure was inadequate to curb the massive staff turnover in the province noting that the Department was aligning itself to the guidelines before the project could be implemented.

The Chair noted that the Inter-Governmental Fiscal Review was promoting the idea of decentralizing services from district hospitals to the PHC facilities yet the Department had allocated 68% of its budget to the district hospitals and 32% more to the PHC.

Dr. Manzini explained that since much of the work on the PHCs was happening in the district hospitals, the Department was bound to a conscious decision to combine the budget for the PHC and that of the district hospital.

The Chair noted that the Department indicated that hospital revitalization program was the reason for budget cuts and yet the National Department funded this programme.

Ms Baloyi asked the nature of co-operation the Department got from the National Department in its drive to close the inter-provincial inequity gap.

Mr. Moloto informed the Committee that his Department, indeed, had a good working relationship with the National Department. However when it came to the issue of inequity in the provincial budget allocations the National Department would always point fingers to the National Treasury siting the example of funds for hospital revitalization where only figures were shown but not confirmed.

Dr. Jassat asked if the Department received any donor assistance and if so what it had achieved with such funds.

Mr. Moloto explained that donors for the most part attached near impossible conditions to their assistance and that without the appropriate infrastructure it was normally difficult to meet these conditions. Donors like the EU sometimes required the Department to first apply its own funds and then seek for reimbursement upon the completion of the project. The Department recently raised its concern to the EU ambassador who promised to take up the matter with his principles.

The Chair took objection to the fact that the Department was combined with that of Welfare noting that it is the only arrangement of the kind in the entire country and stressed that this alignment unnecessarily increased the weighty of the burden the Department had to carry.

Briefing by Dr. Gosnell - Head of Department North-West Province
Dr. Gosnell stated that the Department's vision was to offer an optimum health service for all individuals and communities in the North West Province. The Department would ensure access to affordable, equitable, quality, caring health services for all in the North West Province. This goal would be achieved through: Community involvement and partnerships; Batho Pele Principles and the Patients' Rights Charter; Innovation driven performance; and by valuing people and their diversity. The Department envisaged a well-managed and effective District Health System that was driven by a competent, empowered and performance focused employees. The Department endeavoured to put in place appropriate and effective organizational systems that would strive to deliver quality health services to its inhabitants.

Dr. Gosnell reported that so far the Department had established 322 VCT and that a total of 1310 Nurses had been trained in rapid testing while another 664 nurses had been trained in counselling. The PMTCT facility was district based and that these sites had increased from 2 to 89. More than 1333 care givers were trained in HBC Department and that in addition 24 private doctors had been trained in the management of STI, as well as 320 traditional healers. So far the Department had distributed 2,080 condom at designated points and these included 22,208,331 male condoms and 210 837 female condoms.

Dr. Gosnell informed the Committee that 20 new fully equipped surgeries with state of the art equipment were opened between 2000 and 2002 out of which 80% were based in rural areas. He reported that the number of out reach clinic visits had witnessed an increase of 30% and that preventive services on the other hand had increased by 35%. He continued that conservative dentistry services had also increased by 30 % while curative services in areas where there was no such service had increased by 100 % as new more clinics where opened. The quality of services for the management and prevention of HIV/Aids & TB cases had significantly improved noting that clinic supervision and hospital accreditation had been established.

Discussion
The Chair faulted the Department's report for failing to clearly outline the expenditure its patterns.

It was stated that unlike in the past the Department had now realized a significant increase in its budget noting that Education had traditionally taken the lion's share of the budget. The province still grappled with the question of equity in its budgetary allocation. He referred members to the Department's strategic plan, which sets out in sufficient detail the expenditure patterns.

Dr. Cachalia asked if the Department had developed a follow up mechanism to ensure that all its projects were implemented according to specification.

Dr. Cachalia commended the Department for the effort it has expended which seeks to attract private patients to its institutions with a view to tap into the lucrative reserves that was offered by the medical scheme facility. He nonetheless expressed reservation as to whether the Department would be able to retain the expertise demanded by the private patients in order to sustain this vital programme.

Dr. Gosnell explained that the Department would offer differentiated amenities in its bid to attract private patients noting that the issue really was the quality of services offered that would matter here. The Department was convinced that there was a great potential to tap into this area.

Dr. Luthuli (ANC) noted that the incidence of syphilis had drastically reduced yet other STIs remain constant. Why was this the case?

Dr. Gosnell admitted that the issue regarding the decrease of syphilis cases whilst other related STI remained undisturbed was a rather puzzling development but he attributed the turn-around on syphilis to the aggressive awareness campaign the Department had impact on in the recent past.

Dr. Luthuli noted that the province was largely rural and asked how the Department coped with the provision of ambulance services. She also asked if the Department experienced difficult in the come back time for the TB patients.

Dr. Gosnell replied that the Department had a range of interventions with regard to the TB treatment regimen, some of which included the provision of mobile clinics, and through family or community members. The Department's ambulance system had come to an abrupt halt especially in deep rural areas. The availability of mobile services had a positive effect on the incidence of morbidity which reflected the quality of the clinical services that are made available.

Ms Jacobus (ANC) asked what the nurse-patient ratio was like in the province.

Dr. Gosnell replied that the Department did not, unfortunately, have data on the ratio of nurse to patient but only that of doctor to patient noting that in the case of the later the province ranks second lowest. He promised to look into the issue of how to develop data on the nurse to patient ratio.

Ms Malumise asked why there was an under-spending on the hospital infrastructure.

Dr. Gosnell explained that the Department partnered with the Department of Public works in matters of improving hospital infrastructure noting that due to a delay in the tendering process and other related logistic problems work started late and hence the item of under-expenditure.

Ms Baloyi asked what the Department was doing to increase the TOP services in the province.

Dr. Gosnell replied that each year the Department marketed the roll-out of TOPs but that the process was often hampered by negative attitudes in spite of the fact that new sites were opened each year. The Department had experienced a very low rate of attendance this year since most people preferred to go to Gauteng province.

Ms Baloyi sought comment on the expansion of the PMCT project in the province.

Dr. Gosnell explained that the Department's programme for the expansion of the PMCT facility was pegged on district targets in all hospitals and centres adding that the Department was also looking into ways and means to make the programme accessible to clinics as well.

Ms. Baloyi asked what the Department was doing to train nurses in the management of ANC at its health facilities.

Dr. Gosnell replied that the Department was addressing the incidence of maternal death through training and educating programmes and monthly seminars to identify what caused the deaths and measures to prevent recurrence. The Department had, however, been plagued by the problem of delayed referrals and that measures were being put in place to address this important challenge

Ms. Baloyi wanted to get a feel of the nature or state of infrastructure the Department had on its information systems.

Dr. Gosnell reported that the Department was currently working on a project to establish core centres and develop an effective information system for district health facilities noting that in general the provincial information system infrastructure remained largely undeveloped.

Dr. Luthuli noted that many patients still went to district hospitals for treatment yet it was a deliberate government policy to decentralize health services in order to develop a functional referral system. She enquired why patients chose to go to district hospitals rather than health centres.

Dr. Gosnell explained that over the years the Department had witnessed a relative decline on the number of people visiting the district hospitals noting that roughly 1/3 of the budget was spent on the PHCs programme. The Department was in fact working hard to expand and improve the quality of service offered at the PHCs establishments noting that the Department had devised a mechanism for a daily doctor visit to these facilities.

Ms Malumise asked about the number of children that have tested positive since the establishment of the VCTs sites. She noted that the initial sites for VCTs were started more than two years ago and wondered whether the Department had planned to spread this facility to the rest of the province. It would be helpful to enlighten members on the Department's experience regarding the management of these sites so far.

Dr. Gosnell replied that so far nine children had tested positive since the project was launched noting that the number would have been higher had the project not been up and running. He concurred that the programme should be expanded since it was a very positive project and promised to look into the issue afresh.

The Chair noted that the Inter-Governmental Fiscal Review had shown that the Department's budget has increased by 27% and asked what business plans the Department had put together to absorb this significant increase.

Dr. Gosnell lamented the fact that there was a huge gap between the programs the Department wished to roll out especially in deep rural out posts and the resources put at its disposal. He pointed out for instance the lack of supervision for junior cadre of hospital personnel that were posted in rural areas noting that the incentive package would go along way to address this deficiency but clearly there was still a huge ground to be covered. He referred members to the presentation (attached) which gives a detailed analysis of the budgetary allocation, and the expenditure pattern had been clearly tabulated.

The Chair noted with satisfaction that the province had a ratio of one doctor to 3000 patients but faulted the Department for not outlining plans to utilize the incentive package to attract health professions.

Dr. Gosnell reported that the Department had received a sum of R 120 million to capacitate the personnel component and that there were plans to develop a range of incentives to attract all calibre of health professionals and at the same time improve emergency and financial services in district hospitals.

Briefing by Dr. M H Hendricks HOD - Northern Cape
Dr. Hendricks informed the Committee that the Department's vision was to achieve excellent, historic, people- centred and affordable health care in the Northern Cape. This would be achieved through a decentralized, accountable, accessible and constantly improving health care system within available resources. The Department's caring, multi-skilled, effective personnel would use evidence-based, informative health care and maturing partnerships for the benefit of its clients and patients.

Emphasis would be put on accelerated service delivery noting that one of the major areas of concern to be addressed rates through integrated strategic interventions was the decreasing morbidity and mortality. Other key areas were namely: revitalization of hospital services, improving human resource development and management, reorganization of support services, legal reform programme and improving resource mobilization and management of resources without neglecting the attainment of equity in resource allocation among other targets.

Dr. Hendricks reported that the equitable allocation to the Department of Health was increased from R488, 062 million to R564, 818 million, an increase of 15.73% while the conditional grants allocation was increased from R110, 152 million to R171, 694 million an increase of 55.9%. This large increase in conditional grants was attributed to the substantial increase in the allocation of two conditional grants, namely the Integrated Nutritional Programme and the Hospital Revitalization Grant. This grant increased by more than 100% each in the 2003/04 financial year as compared to the previous year. Capital allocation received a substantial 51.6% increase in the current financial year as compared to the previous years' adjusted budget bringing the total capital allocation to R79,523 million. This allocation represented 11% of the budget and was funding mainly the construction of Colesberg and Calvinia Hospitals.

Hospital services had been overhauled in line with Departmental Strategic Position Statement recommendations, which outlined measures on Human Resources Development and Redistribution of Tertiary Services Grants. There had been and equitable distribution of limited resources through the largest geographic area in the country. In an attempt to curb the uncontrolled migration of nurses, the Department had introduced a nurse scholarship program in conjunction with the Oxford Radcliffe Hospital in the United Kingdom. The programme which was jointly funded by the EU had already trained its first batch of 14 nurses who left Kimberly Hospital Complex for the course that lasted six months and the group returned to the country at the end of January 2003. The increase of tertiary services at the Kimberly hospital, the Department had drastically reduced its reliance on other provinces and the private sector for specialized services.

Discussion
Ms Mabeta (ANC) observed that the report was unambiguous and one that clearly demonstrated what the Department was doing and that the in-put had touched on every area of interest to the Committee. The report would be closely studied and a visit to the province would allow the Committee to see what was happening on the ground.

Ms Baloyi said that she wished to reiterate and fully endorse the sentiments expressed by Ms Mabeta noting that the Department's in-put was the kind of material the Committee expected from other provinces. This material was very essential for the Committee's oversight work and concurred with Ms Mabeta's proposition to visit the province at some point in order to learn from its service delivery experience. She expressed concern at the increase intake of alcohol by the school going children which she blamed for the high school drop out rate. The Department was commended for its aggressively innovative human resource development programme. Was the PMCT programme national or provincial based?

Dr. Hendricks replied that the PMCT program was a national initiative.

Ms Baloyi asked the Department to highlight the item on overspending and under-spending on various health services.

Dr. Hendricks explained that the incidence of under-spending occasioned by delay in construction of a building that was designated to house pharmaceutical stores. No alternative building was immediately available and the Department was forced to use the Kimberly hospital. Due to this relocation Kimberly hospital was used to purchase all medical stores hence occasioning over-spending on hospital services and the corresponding under-spending for pharmaceuticals.

Ms. Mathibela (ANC) asked who the Department used to train nurses on how to handle domestic violence patients.

Dr. Hendricks replied that the Department enlisted the services of two Free State University lecturers to run the programme on forensic training in domestic violence noting that the programme had considerably enhanced the conviction rate against culprits.

Ms Malumise pointed out that the Northern Cape had traditionally had the lowest prevalence rates for Aids in the country and wondered why there had been a steep increase in the reported cases.

Dr. Hendricks concurred with Ms Malumise that the province had experienced a major jump in HIV/Aids cases but noted that the Department still awaited the 2002 statistics in order to get the true picture of the current rate of prevalence. The Department had put in place all the support programs to arrest and manage HIV/Aids and that indeed the decline in teenage pregnancies went along way to vindicate the view that the Department was succeeding.

The Chair commended the programme relating to the development of human resource capacity. He also lauded the Department for the effort it had made in improving its ambulance services, which was quite innovative. The key task that members were confronted with was to delve into the various reports in order to come up with their own analysis upon which the house could then engage the National Department. He repeated his earlier instruction that Mpumalanga and Kwazulu Natal provinces would be recalled to resubmit their respective reports.

The meeting was adjourned.